“We’re doing it wrong,” said Jennifer Aist, Director of the Maternity Outpatient Clinic at Providence Alaska Medical Center. She has 20 years experience as an International Board Certified Lactation Consultant (IBCLC) and is one of many breastfeeding advocates in the U.S. to note the need for a new approach to breastfeeding promotion. One that shifts the focus from what is wrong with mothers who stop (or never begin) breastfeeding to what is wrong with a society that makes breastfeeding so difficult that it is sometimes impossible.

“It’s a mess,” said Aist. “But you have to go back to what got us into this huge mess in the first place….a formula campaign that convinced every woman on the planet that their milk was not adequate.” Formula manufacturers cleverly preyed upon the emotions of vulnerable women with aggressive marketing techniques that influenced public health and suppressed breastfeeding rates through the 1970s.1 “That’s what we’re battling against when we do all our breastfeeding promotion,” said Aist.

THE SHAME OF NOT BREASTFEEDING

"It’s easy to equate breastfeeding with being a good mom and put everything else secondary to that," says Annah Burgess, RN, IBCLC. "At some point that’s not healthy."

While there is a lot of work to do to diminish racial breastfeeding disparities, promotion has been largely successful. All national healthcare organizations now recognize breastfeeding as the nutritional ideal for infants and breastfeeding rates have quadrupled since 1972.

But in that push to undo the damage done by the formula campaign, advocates introduced the ideas of ‘breast is best,’ ‘all women can breastfeed,’ and the danger of ‘just one bottle’, and then framed it all as a choice conflated with ideal motherhood and femininity.2,3,4 What the messaging doesn’t address is that 5% of women don’t ever produce enough milk to breastfeed5, most women experience a spectrum of physiological challenges,6 and all women encounter difficulty breastfeeding from the lack of structural and social supports in the United States.3,7

In many parts of the country this approach progressed social norms but not social practices - what women are told they should do has become disconnected from what women can do. As a result, alongside the continued stigma of breastfeeding in public, there is now a stigma associated with formula feeding your infant. Annah Burgess, an RN and IBCLC at Skagit Valley Hospital in rural Washington, sees mothers go through a mourning process after they have struggled, but ultimately failed, to breastfeed. “And then they feel judged out in public when they are giving bottles and formula to their babies. There are other moms who basically will say to them, ‘you just didn’t try hard enough.’”

Without acknowledging and publicizing what makes breastfeeding difficult, the movement and its advocates place the burden of a woman’s decision to stop breastfeeding early (or not to start) entirely on her. This leaves women feeling deficient while they experience hormonal shifts, sleep deprivation, residual pain, and the responsibility of a tiny, new life.3,4,8

HOW PUBLIC HEALTH CAN PROMOTE BREASTFEEDING, MITIGATE SHAME, AND IMPROVE RATES

Normalize the challenges of breastfeeding

Existing efforts to normalize breastfeeding should include the struggles of breastfeeding and recognize the necessary role of formula.3 Aist calls it the ‘hierarchy of milk.’ Rule number one: feed your baby. First choice, breast milk. Second choice, donor milk. Third choice, infant formula.

A grassroots breastfeeding campaign changed the system in Oregon.Read more...

Four out of ten new mothers have delayed onset milk9, and that’s only one of the many medically-indicated reasons to supplement. Women who have internalized messages about the ills of formula will agonize over every ounce they feed their babies. “I would never tell a mother [who had to supplement] that there’s nothing wrong with formula. That’s lying to her. That’s not informed consent,” said Aist. But she explains to her patients that sometimes the need to feed your baby outweighs the risks associated with formula.

Mobilize women to eliminate the structural constraints on breastfeeding

Messaging should frame breastfeeding as a “right” rather than a “choice” and increase public awareness of the structural and social barriers to breastfeeding. This includes lack of paid maternity leave and poor (or absent) breastfeeding accommodations at work and in public spaces.3,4,7

More active support, especially postpartum

94% of low-income moms of color are still breastfeeding at six months after weekly visits from these doulas...

Aist added that policies should direct practical breastfeeding education at families - the husband, partner, grandmother, auntie, or anyone else who goes home with the mother.

Emphasize a woman-centered experience of breastfeeding

The creation of messaging and policy should include input from mothers, be structured to allow practitioners to take a more collaborative approach with patients, and recognize that focusing on the well-being of the mother is also supporting the child.4,8,10 Policymakers should recognize that a mother’s emotional well-being can also significantly impact infant development.8

“It’s not only about breastfeeding. We have to take care of moms, we have to take care of the unit," said Burgess. "And we do have to establish that breastfeeding is the norm...It’s healthiest, it’s what’s best for you and your baby," she explained. "But also, we have to teach people we should be more compassionate to mothers, period. Because we’re not.”